Hoofd-Hals Journaal. H alst u m. Jaargang 15. In dit nummer: Optische spectroscopie Gehoorschade EHNS-congres Lille Lustrumcongres NWHHT

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1 Jaargang 15 se Werk d n a l g r r e en H oo p oe Ne d Hoofd-Hals Journaal fd- H alst u m r o In dit nummer: Optische spectroscopie Gehoorschade EHNS-congres Lille Lustrumcongres NWHHT Hoofd-Hals Journaal 30

2 colofon Redactioneel De Nieuwsbrief van de Nederlandse Werkgroep Hoofd- Halstumoren wordt uitgegeven in samenwerking met Kloosterhof acquisitie services Hoofdredacteur Dr. L.E. Smeele, kaakchirurg Eindredakteur Prof dr. A Vermey, chirurg Redactieleden Mw. M.G. van Driel, oncologie verpleegkundige Mw. E. de Haan, logopedist Dr. S.O.P. Hofer, plastisch chirurg Prof dr. C.R. Leemans, kno-arts Prof dr. P.C. Levendag, radiotherapeut Dr. C.R.N. Rasch, radiotherapeut Prof dr. J.B. Vermorken, internist-oncoloog Prof dr. Th. Wobbes, chirurg Secretariaat M.S.C. van Heerden-van Putten Postbus 1374, 3430 BJ Nieuwegein Tel: , fax: vanheerden@wxs.nl Bladmanagement Kloosterhof Acquisitie Services, Kruisstraat 2, 6086 AR Neer De heer H.G.P. Vullers info@kloosterhof.info Telefoon: , fax Internet: Grafische verzorging M2 Reclame- Ontwerpbureau Telefoon: , GSM emtwee@euronet.nl Auteursrecht en aansprakelijkheid Alle rechten zijn voorbehouden. Niets uit deze uitgave mag worden verveelvoudigd, opgeslagen in een geautomatiseerd gegevensbestand of openbaar gemaakt, in enige vorm of op enigerlei wijze, hetzij elektronisch, mechanisch door fotokopieën, opnamen of enige andere manier, zonder voorafgaande schriftelijke toestemming van de uitgever. Uitgever en auteurs verklaren dat deze uitgave op zorgvuldige wijze en naar beste weten is samengesteld; evenwel kunnen uitgever en auteurs op geen enkele wijze instaan voor de juistheid of volledigheid van de informatie. Uitgever en auteurs aanvaarden dan ook geen enkele aansprakelijkheid voor schade van welke aard dan ook, die het gevolg is van handelingen en/of beslissingen die gebaseerd zijn op bovenbedoelde informatie. Gebruikers van deze uitgave wordt met nadruk aangeraden deze informatie niet geïsoleerd te gebruiken, maar af te gaan op hun professionele kennis en ervaring en de te gebruiken informatie te controleren. ISSN-nr In de Biblioteca Medicea Laurenziana in Florence wordt een middeleeuws manuscript bewaard, dat handelt over 'het gebouw der kennis' (Thebit de scientia imaginum, sive variorum opera, partim Astronomica, partim etiam moralia). De auteur, waarschijnlijk een monnik, is onbekend en stamt vermoedelijk uit de 14e of 15e eeuw. De inhoud is gebaseerd op eerder werk van de dominicaan Francesco Bonaccorso ( ) uit Bologna, en bevat onder meer een afbeelding die wij tegenwoordig een tabel zouden noemen: rijen en kolommen die met elkaar meer dan honderd velden vormen, met in elk veld bepaalde informatie. Door de onderlinge samenhang en hiërarchieën die zo ontstaan, kunnen de relaties tussen de velden worden afgelezen en vooral worden gememoreerd (destijds waarschijnlijk de belangrijkste functie). De tabel bevat in eerste oogopslag slechts een opsomming van allerlei christelijke 'deugden'. Maar er is meer aan de hand. De tabel wordt een gebouw doordat zij wordt gestut door vier allegorische pilaren, voorstellende de belangrijkste deugden: Prudentia (inzicht), Fortitudo (vastberadenheid), Justitia (gerechtigheid) en Temperantia (gematigdheid). Naarmate men hoger in het zo ontstane gebouw opstijgt doorloopt men (letterlijk weergegeven door een trap) de hiërarchisch gerangschikte stadia van ontwikkeling, die uiteindelijk leiden tot een spirituele volmaaktheid, naar middeleeuwse normen uiteraard. Door de afbeelding uit het hoofd te leren ontstaat in het bewustzijn van de lezer een representatie ervan die uiteindelijk leidt tot diens volmaakte spirituele ontwikkeling. De schoonheid van dit eeuwenoude concept is niet alleen ontroerend maar geldt bovendien nog steeds. Door de weergave van abstracte waarden op een manier die wordt ingegeven door een spiritueel gevoel, symboliseert het de vermenging van rationele wetenschap en menselijke betrokkenheid die velen van ons zullen ervaren in het contact met onze patiënten. Met deze woorden wens ik, mede namens de redactie, onze lezers veel bevlogenheid toe in Ludi Smeele Nederlandse Werkgroep 3

3 inhoudsopgave Optische spectroscopie als diagnosticum voor premaligne afwijkingen 5 Gehoorschade bij parotisbestralingen 7 2nd European conference on head and neck cancer 9 Redactioneel 3 Optische spectroscopie als diagnosticum voor premaligne afwijkingen 5 EORTC 24 Gehoorschade bij parotisbestralingen 7 Bestuurswisseling 8 2nd European conference on head and neck cancer 9 7th Symposium on research in head and neck cancer 16 2nd International conference on sentinel node biopsy in mucosal head and neck cancer 22 NWHHT Research meeting 23 Lustrumvergadering NWHHT 40 EORTC Head and Neck Cancer Cooperative Group 24 Evaluatie oprichtingssymposium PWHHT 29 Najaarsvergadering Ned.Ver. voor Mondziekten en Kaakchirurgie 30 Referaat 36 Proefschrift van E.J.C. Nieuwenhuis 37 Proefschrift van I. Verel 38 Lustrumvergadering NWHHT 40 Agenda 42 Nederlandse Werkgroep 4

4 spectroscopie M.J.H. Witjes, D.C.G. de Veld, H.J.C.M. Sterenborg, J.L.N. Roodenburg Afdeling Mondziekten & Kaakchirurgie, Academisch Ziekenhuis Groningen De informatie in licht: optische spectroscopie als diagnosticum voor premaligne afwijkingen Het fenomeen fluorescentie werd voor het eerst begrepen (het wordt al duizenden jaren waargenomen) door Stokes in Vanaf het begin van de 20e eeuw werd getracht fluorescentie aan te wenden voor diagnostiek in de geneeskunde. Aanvankelijk werd er gebruikgemaakt van de aanwezige fluorescerende moleculen in humaan weefsel (autofluorescentie). In de jaren verschoof de aandacht naar fluorescentiedetectie van tumoren met behulp van toegevoegde fluorescerende stoffen (exogene fluoroforen of photosensitizers) door de ontwikkeling van het hematoporphyrinederivaat. Deze stof werd intraveneus ingespoten en lokaliseerde zich bij een groot aantal patiënten in de aanwezige tumor. De eerste experimenten met de stof in het hoofdhalsgebied werden in 1971 uitgevoerd. Nadelen van deze exogene fluoroforen is dat ze lang in de patiënt blijven, met als gevolg dat patiënten langdurig in een donkere kamer moesten blijven om ongewenste reacties op licht te voorkomen. Door de ontwikkeling van potentiële photosensitizers kwam dit onderzoeksveld tot bloei. Vooral de technische ontwikkelingen zorgden ervoor dat er gevoeliger gemeten kon worden. Hierdoor bleek het mogelijk om zonder toevoeging van exogene fluoroforen toch afwijkingen te kunnen detecteren met autofluorescentie. Inmiddels is de techniek verfijnd voor experimentele studies in verschil- lende disciplines. In feite kan autofluorescentiespectroscopie worden toegepast daar waar het weefsel bereikbaar is voor een endoscoop. In de mondholte wordt door de auteurs al enkele jaren getracht om laesies te classificeren op basis van het autofluorescentiespectrum. Er werd een klinische studie verricht om de waarde van autofluorescentiespectroscopie te evalueren. De experimentele opstelling bestaat uit een Xenon lamp met een monochromator om de gewenste golflengte te selecteren. Het excitatielicht wordt via glasvezels ( fiber ) geleid naar een handstuk dat in de mond kan worden gebruikt. Het fluorescentielicht wordt in een andere bundel glasvezels in hetzelfde handstuk opgevangen en naar een computer geleid voor spectroscopische analyse. Met deze opstelling werd een groep patiënten (155) en vrijwilligers (97) onderzocht om een beeld te krijgen van hoe autofluorescentie van normaal mondslijmvlies eruit ziet afgezet tegen allerlei afwijkingen van het mondslijmvlies. De resultaten lieten zien dat het normale slijmvlies van de gehele mond spectroscopisch Fig. 1 Overzicht van de opzet van het onderzoek Nederlandse Werkgroep 5

5 spectroscopie Een opvallend fenomeen is dat roken en gebruik van alcohol de autofluorescentiespectra van orale mucosa significant verandert. De veranderingen zijn deels ook nog afhankelijk van de hoeveelheid sigaretten en alcohol die gebruikt werd. Fig.2 Autofluorescentiespectra van gezond mondslijmvlies, benigne afwijkingen, dysplasie en plaveiselcelcarcinoom, gemeten op de randen en in het centrum van de afwijkingen (excitatie 420 nm.). Fig.3 Autofluorescentiespectra van klinisch normaal mondslijmvlies bij rokers en niet-rokers. Er bestaat een duidelijk verband tussen het aantal per dag gerookte sigaretten en de spectrale afwijking. niet verschillend is, behoudens de mucosa van de tongrug en het lippenrood. Deze twee typen slijmvlies zijn spectroscopisch anders, vermoedelijk vanwege de doorbloedinggraad en de aanwezige fluorescerende stoffen geproduceerd door micro-organismen. Autofluorescentiespectra werden gemeten van 172 slijmviesafwijkingen (benigne, dysplastisch en maligne) bij 155 patiënten. Er werden spectra gemeten van 460nm tot 750nm bij excitatie met zes verschillende golflengten. Gemeten werd in het centrum, de rand en de omgeving van de laesie evenals aan de contralaterale zijde. Met Principal Component Analysis, een artificieel neuraal netwerk en golflengteratio s, werd getracht om de verschillende groepen (gezond, benigne, dysplastisch, maligne) te onderscheiden. Het was goed mogelijk om maligne weefsel van normaal te onderscheiden, namelijk in meer dan 90% van de gevallen. Het onderscheiden van benigne en maligne laesies lukte in 75% van de gevallen en bij dysplastisch vs maligne in 82%. Echter, het bleek lastig om een onderscheid te maken tussen benigne en dysplastische laesies (50%) terwijl dit onderscheid klinisch het meest relevant is. Deze resultaten laten zien dat de informatie in licht op dit moment nog niet leidt tot een methode waarmee slijmvliesafwijkingen betrouwbaar kunnen worden geclassificeerd. Verdere verfijning van de methode, gecombineerd met andere optische technieken, zal mogelijk kunnen leiden tot correcte classificatie van deze afwijkingen. 6

6 parotisbestraling Gehoorschade bij parotisbestraling Mw. E. Lamers NKI/AvL Bij patiënten die in het verleden bestraald zijn voor een parotistumor blijkt ipsilateraal gehoorschade op te treden. De tot dusver gebruikte techniek is een unilaterale bestraling door middel van twee wigvelden, waarbij het midden- en binnenoor zich gedeeltelijk in het bestralingsveld bevinden. Door tympanometrie en audiometrie is gehoorschade vast te stellen. Al in 1994 is er in een studie bij 21 patiënten aangetoond dat in 50% van de gevallen waar het binnen- en middenoor zich in de bestralingsveld bevindt, gehoorschade optrad, zowel conductief als neurosensitief. De schade trad vooral op bij doses boven de 50Gy op de cochlea. 1 Deze resultaten werden bevestigd door Chen et al. in Hier werd de schade aangetoond bij een dosis van meer dan 60Gy op de cochlea. Ook in ons eigen instituut werd een soortgelijk onderzoek gedaan. De hierbij aangetoonde gehoorschade was voornamelijk neurosensitief en trad op bij 1-2, 4-8 en khz met toenemende frequentie; conductief gehoorverlies ontstond bij Hz. Er bleek een dosis-effect relatie te bestaan bij 4-8 khz. Een dosis van minder dan 55Gy op de cochlea gaf zelden gehoorverlies in tegenstelling tot een dosis van meer dan 65Gy. 3 Door de modernere bestralingstechnieken als Intensity Modulated RadioTherapy (IMRT) lijkt het mogelijk om nauwkeuriger te bestralen en de omringende weefsels te sparen. De gehoorschade zou dan verminderd, of zelfs vermeden kunnen worden. Aangezien er de laatste jaren veel vooruitgang is geboekt met de toepassing van IMRT, zou een soortgelijke techniek ook bij bovengenoemde patiënten toepasbaar kunnen zijn. Het doel van het onderzoek was een nieuwe techniek te ontwikkelen, waarbij gehoorschade verminderd of zelfs vermeden kan worden. Daarbij ervan uitgegaan dat het doelgebied minstens zo goed bestraald zou worden als met de conventionele techniek en dat de dosis in kritieke organen zoveel mogelijk beperkt zou worden. Twintig recent bestraalde personen met een parotistumor werden geselecteerd. De patiënten werden allemaal met twee verschillende technieken berekend. De eerste techniek is de standaard behandeling: 2 oblique wigvelden (anterior en posterior) met mal, 4 MV. De tweede techniek is een IMRT techniek waarbij, door gebruik te maken van speciale software, een optimaal bestralingsplan wordt ontworpen. Hierbij wordt gebruikgemaakt van vooraf inge- Afb.1 Conventionele techniek (links) versus de IMRT techniek. Duidelijk zichtbaar is de afname van dosis in de mondholte, cerebellum, myelum en het gehoororgaan. Het doelvolume wordt meer conform bestraald. 7

7 parotisbestraling stelde optimalisatie-parameters om de omringende kritieke organen zoveel mogelijk te kunnen sparen. Zo worden er bepaalde eisen gesteld aan bijv. de maximale dosis op het myelum, of de gemiddelde dosis op de mondholte. Na evalutie van de gegevens (dosisvolume histogrammen) bleek dat het mogelijk is om het gehoororgaan te sparen. Dat kon alleen als de afstand van het binnenoor tot het doelvolume meer dan 0.6 cm is en het volumepercentage overlap van het doelgebied met het middenoor niet meer is dan 10%. Ook de gemiddelde dosis op de mondholte bleek aanzienlijk verlaagd te kunnen worden. Voor de overige kritieke organen geldt dat de dosis lager is in het IMRT-plan, terwijl het doelvolume minstens gelijk bestraald wordt als met de standaardtechniek. Referenties: 1. Anteunis LJ, Wanders SL, Hendriks JJ, Langendijk JA, Manni JJ, De Jong JM., A prospective longitudinal study on radiationinduced hearing loss. Am J Surg 1994;168: Chen WC, Liao CT, Tsai HC, Yeh JY, Wang CC, Hong JH. Radiation-induced hearing impairment in patients treated for malignant parotid tumors. Ann Otol Rhinol Laryngol 1999;108: Schot LJ, Hilgers FJ, Keus RB, Schouwenburg PF, Dreschler WA, Late effects of radiotherapy on hearing, Eur Arch Otorhinolaryngol 1992; 249: Bestuurswisseling Per 1 januari 2004 zal dr. J.H.A.M. Kaanders, Nijmegen, de voorzittershamer overdragen aan dr. B.F.A.M. van der Laan, Groningen Dr. Kaanders maakt sinds 1994 deel uit van het Algemeen Bestuur van de NWHHT, als vertegenwoordiger van de Nijmeegse Hoofd- Halswerkgroep. In 1996 kwam hij in het Dagelijks Bestuur en in 2000 volgde hij prof. dr. I. van der Waal op als voorzitter van de NWHHT. 8

8 congresverslag 2 nd European conference on head and neck cancer. Prof.dr. C.R. Leemans VUmc, Amsterdam Lille Frankrijk oktober 2003 Tijdens de eerste succesvolle conferentie in Lille in 2001 werd afgesproken te streven naar een Europese tegenhanger voor de American Head and Neck Society. Dit plan werd van harte ondersteund door de Oprichtingsbestuur 2003 van de EHNS van links naar rechts: Jan Olofsson, Dominique Chevalier, Jean Louis Lefèbvre, René Leemans, Newell Johnson, Guy Andry International Federation of Head and Neck Oncologic Societies (IFHNOS). Van 17 tot 18 october 2003 werd in Lille, Frankrijk, de Second European Conference on Head and Neck Cancer gehouden. Deze conferenties kunnen beschouwd worden als de voortzetting in uitgebreider zin van de vroegere gezamenlijke bijeenkomsten van de NWHHT met zijn Britse en Scandinavische zusterverenigingen, uitgebreid met Franse en Belgische hoofd-halsorganisaties. Tijdens deze opnieuw goed bezochte conferentie werd een bijeenkomst belegd van de verschillende Europese vertegenwoordigers van nationale verenigingen en werkgroepen waar in totaal 27 mensen uit 15 landen deelnamen. Vastgesteld werd dat de tijd voor een European Head and Neck Society (EHNS), onder de paraplu van de Federation of European Cancer Societies, gekomen was. De vereniging zal een individueel en collectief lidmaatschap (artsen en paramedici) gaan kennen en zal ten doel hebben om de uitwisseling van kennis in alle aspecten van hoofd-halstumoren te bevorderen evenals de hoogste standaard van onderzoek, onderwijs en opleiding. De nationale vertegenwoordigers benoemden voor de periode tot de derde European Conference on Head and Neck Cancer in 2007, wanneer de leden een bestuur kunnen kiezen, als oprichtingsbestuur de volgende groep (zie foto): Jean Louis Lefèbvre (voorzitter, Frankrijk), René Leemans (secretaris), Dominique Chevalier (Frankrijk), Newell Johnson (Verenigd Koninkrijk), Jan Olofsson (Scandinavië) en Guy Andry (België). Deze groep, die ook de organisatie van de eerste twee conferenties op zich had genomen, zal zich o.a. bezighouden met het opstellen van de statuten, de reglementen, ledenwerving, opzetten van een website van de nieuwe organisatie en zal uiteraard contact houden met de IFHNOS en de nationale groepen. 16 oktober, Satellite symposium Merck Voorafgaand aan de conferentie werd een door Merck, Darmstadt, Duitsland gesponsord satelliet symposium gehouden onder te titel 9

9 congresverslag Head and Neck Cancer, where do we go from here?, mede georganiseerd door Jean Louis Lefèbvre. Op dit symposium werden de volgende voordrachten gehouden: Magnitude of the Problem door Jean Louis Lefèbvre (Lille, Frankrijk): over incidentie, levensstijl (alcohol-tabak), co-morbiditeit, stadiëring, uitkomstparameters voor de vroege (tweede primaire tumoren) en late stadia, (gevolgen van ingrijpende behandelingen, locoregionale recidieven, afstandsmetastasen) en resultaten van behandeling voor zeer vergevorderde ziekten en recidieven. Recent Advances in Radiation Therapy door Jacques Bernier (Bellinzona, Zwitserland): veranderde fractioneringen, conformatie radiotherapie, intensity modulated radiation therapy (IMRT), 3D planning en selectieve radiotherapie. Recent Advances in Surgery door René Leemans (Amsterdam): functionele-, laser- en selectieve chirurgie, schildwachtklier, reconstructieve chirurgie, inclusief vrije lappen en salvage surgery. Meta-analysis on Chemotherapy in Head and Neck Cancer door Jean Bourhis (Villejuif, Frankrijk): de twee 2 meta-analyses uitgevoerd in Institut Gustave Roussy. Where do we go from here? door Jan Vermorken (Antwerpen, België): nieuwe moleculaire aangrijpingspunten voor combinatietherapie. 2nd European conference on head and neck cancer oktober 2003 Samenvattingen van de Nederlandse bijdragen Integration of genomic HPV 16 DNA is associated with p16ink4a overexpression in tonsillar carcinomas J.J. Manni, H.C. Hafkamp, M. Schepers, F.J. Bot, A. Haesevoets,.SM.H. Claessen, A.H.N. Hopman, F.C.S. Ramaekers, E.J.M. Speel, Maastricht Background: In a previous fluorescence in situ hybridization (FISH) study, we observed human papillomavirus (HPV) type 16 DNA integration in the tumor cell genome in 21% of head and neck squamous cell carcinomas, particularly in tonsillar carcinomas. Because also no p53 mutations in exons 5-8 were detected, this subset of tumors may comprise a distinct pathological entity. In order to further substantiate this hypothesis, we analyzed p16ink4a expression in 81 tonsillar carcinomas, because p16ink4a has been reported to be a specific marker for oncogenic HPV-containing (pre)neo-plastic lesions of the uterine cervix. p16ink4a expression, clinical data as well as tobacco and alcohol consumption of patients were correlated with HPV status. Methods: Tissue sections of paraffin-embedded tonsillar carcinomas were subjected to FISH using a HPV 16-specific DNA probe to assess the frequency of tumors exhibiting HPV integration. Subsequent sections were used for immunohistochemical assessment of p16ink4a overexpression. Clinical data and alcohol and tobacco exposures of patients were obtained from medical records. Results: FISH detected HPV 16 integration in 33 of 81 (41%) carcinomas, 32 of which also harbored diffuse p16ink4a immunostaining. In contrast, only 5 of 48 HPV-negative carcinomas did stain for p16ink4a. Thus, a very strong correlation was found between p16ink4a overexpression and HPV-containing tonsillar carcinomas (P<0.0001). Furthermore, a significant, inverse relation was found between the presence of HPV in the tumor and tobacco and/or alcohol consumption (P ). HPV-positive carcinomas also showed to be often smaller ( 4 cm) and less well differentiated than HPVnegative tumors (P= and 0.009, respectively). 10

10 congresverslag Conclusions: Our results indicate a remarkable correlation between HPV 16 integration and p16ink4a overexpression in tonsillar carcinomas, resembling the situation for (pre)invasive lesions of the uterine cervix. This suggests that p16ink4a may be considered as an alternative biomarker for HPV detection. Together with the strongly reduced or absent exposure to tobacco and alcohol in these patients, our study provides further evidence for HPV-positive tonsillar carcinomas representing a different tumor entity. Immunological effects of intratumoral rhil-12 administered in head and neck squamous cell carcinoma (HNSCC) patients C. van Herpen, G.J. Adema, P. de Wilde, P.H.M. De Mulder, Nijmegen Background: HNSCC patients have both a local and a generalised immunosuppression. IL-12 promotes the Thelper 1 response and activates and induces a proliferation of cytotoxic T cells and natural killer (NK) cells. Methods: We have performed 2 clinical studies in HNSCC patients with i.t. (rhil-12). In the 1st study (phase Ib) the primary objective was to assess the toxicity of i.t. administration of rhil- 12, 6 recurrent HNSCC patients, who had surgery and radiotherapy before. In the 2nd study (phase Ib-II) the primary objective was to investigate the immunological effects of IL-12, in 10 non-pre-treated HNSCC patients. rhil-12 was injected i.t. in the wait before the surgery. In both studies rhil-12 was administered at two dose levels: 100 and 300ng/kg, once a week. The mean number of administered injections was 9 (3-24) in the 1st and 2 (1-3) in the 2nd study. Results: In the 2nd study the toxicity was more pronounced than in the 1st study, probably due a better immune competence in non pre-treated HNSCC patients. In the 2nd study more and larger lymph nodes were detected in the IL-12 treated versus control patients. Results of flowcytometric analysis of lymphocyte subsets, real-time semi-quantitative PCR analysis of cytokines, Thelper 1 and Thelper 2 transcriptionfactors and immunohistochemistry of immune cells (e.g. dendritic cells) will be presented. Conclusions: rhil-12 at these dose levels and schedule resulted in measurable immunological responses. Second field tumors in oral and oropharyngeal cancer: molecular techniques provide new insights and definitions M. Tabor, R.H. Brakenhoff, C.R. Leemans, B.J.M. Braakhuis, Amsterdam Background: Second primary tumors (SPT) and local recurrences (LR) are a significant problem in head and neck squamous cell carcinomas (HNSCC). Thus far, the definitions of SPT and LR are based on clinical parameters: location and time interval. Methods: Our recent molecular studies have provided new insight in HNSCC carcinogenesis leading to a better understanding of how of SPT and LR develop. Results: A crucial step is the outgrowth of a preneoplastic field of genetically altered cells that precedes HNSCC development. This field has a monoclonal origin and clonal divergence takes place during progression and eventually one subclone develops into carcinoma. The population of genetically altered cells have a high proliferative capacity (as measured by Ki-67 positivity), indicating that fields expand and thereby replace the normal mucosal epithelium. Moreover, fields are shown to be very large (over 7 cm in diameter) and are usually not detected by routine 11

11 congresverslag diagnostic techniques. An important clinical consequence is that fields often remain after surgery and may give rise to (genetically related) new tumors. We have provided convincing evidence for the development of these new tumors and have designated these new tumors: second field tumors (SFT). Considering the etiological differences, we believe it is important to define in molecular terms and discriminate an SFT, a true SPT, and a true LR. Conclusions: The development of an expanding preneoplastic field is a critical step in HNSCC development with important clinical consequences. Diagnosis and treatment of HNSCC should not be focused on the tumor only, but also on the field it developed from. Exogenous and endogenous markers of hypoxia as predictors of outcome in head and neck cancer J. Kaanders, K. Wijffels, H. Marres, H. Peter, L. Pop, F. van den Hoogen, P. de Wilde, J. Raleigh, A. van der Kogel, Nijmegen, The Netherlands and Chapel Hill, NC, USA Background: Hypoxia is associated with tumor aggressiveness and an important cause of resistance to radiation treatment. Assays of tumor hypoxia could provide selection tools for hypoxia modifying treatments. The aim of this study was to correlate the exogenous hypoxia marker pimonidazole with the endogenous hypoxia-related marker carbonic anhydrase 9 (CA9) and with vascular and proliferation parameters. Methods: Pimonidazole and the S-phase marker iododeoxyuridine (IdUrd) were administered intravenously to 43 patients with stage III-IV head and neck cancers before biopsies were taken. Microscopic slides were cut and stained by immunofluorescence for vessels, IdUrd, pimonidazole and CA9. Twenty-three patients were treated with radiotherapy plus hypoxic modification while the other patients received standard treatment. Results: The distribution patterns of pimonidazole and CA9 were similar although CA9 was observed at shorter distances from blood vessels. Locoregional tumor control was significantly lower for patients who had hypoxic tumors or tumors with low vascular density. The 2-year control rates were 48% versus 87% for tumors with high and low pimonidazole binding levels (p = 0.01) and 48% and 88% for tumors with low and high vascular density (p = 0.01). These associations disappeared in the subgroup of patients treated with hypoxic modification. There was no relationship between the level of CA9 expression and treatment outcome. Proliferating cells were rarely observed in pimonidazole positive areas but were more frequent in CA9 positive areas. Conclusions: Pimonidazole binding and vascular density can predict treatment outcome in head and neck cancer and may be useful as selection tools for hypoxia modifying treatments. R. Ljumanovic, J.A. Langendijk, C.R. Leemans, J.A. Castelijns, Amsterdam The prognostic value of pretreatment lymph node parameters in the development of distant metastases in head and neck carcinoma: Value of MRIdetermined parameters Background: To evaluate the prognostic significance of pretreatment MRI-related lymph nodes parameters with regard to the distant metastasis free interval (DMFI) in patients with head and neck squamous cell carcinomas (HNSCC). Methods: Pretreatment MRI studies of 311 patients with HNSCC were reviewed for the presence of minimal-sized lymph nodes at specific levels as well as the presence of lymph node characteristics including extranodal spread, central necrosis and number and volume of ipsi- and contralateral 12

12 congresverslag lymph nodes. Of these patients, 174 (56%) had lymph nodes with an appropriate minimal size (axial diameter > 8 mm with exception at paratracheal and (retro) pharyngeal levels wherein the minimal diameter was 4 mm considered as minimalsized). Results: The 5-years DMFI among patients without minimal-sized nodes on MRI was 85% compared to 72% among those with minimal-sized lymph nodes on MRI. Among the study group with MRI minimal-sized lymph nodes, the presence of extranodal spread (ENS) as detected on MRI was the only independent prognostic factor associated with the DMFI (p = 0.002). Based on this analysis, three risk groups regarding the DMFI could be identified. The low risk group (5- years DMFI: 86%) consisted of patients without minimal-sized nodes on MRI. The intermediate risk group (5-years DMFI: 79%) consisted of patients with minimal-sized nodes on MRI without ENS. Finally, the high risk group (5-years DMFI: 55%) consisted of patients with minimalsized nodes and ENS on MRI (p < ). Conclusions: MR imaging enables selection of patients with a high risk for developing distant metastases (DM). Patients with ENS assessed by MRI are at high risk for developing DM and should be qualify for screening for DM. Endoscopic treatment of early glottic cancer and severe dysplasia/carcinoma-in-situ: the basis of laryngeal preservation R. de Bree, A.J.G.E. Peeters, K.M. Goor, J.A. Langendijk, M. van Agthoven, C.R. Leemans, H.F. Mahieu, Amsterdam Background: For early glottic cancer are several treatment options available: radiotherapy, CO2-laser and (partial) laryngectomy. The aim of this study is to assess oncological, functional and cost-effective outcome of endoscopic treatment for severe dysplasia/carcinoma-in-situ and early (T1a) cancer of the glottis. Methods: Prospective study of 216 patients who were endoscopically treated by means of endoscopic treatment (cordectomy type 1 and 2) for severe dysplasia/carcinoma-in-situ (n=107) or T1a glottic carcinoma (n=109) with a mean follow-up of more than 48 months. Thirty-nine patients underwent radiotherapy for T1a glottic carcinoma. Tumour status, voice quality and overall costs were determined. Results: In the severe dysplasia / carcinomain-situ group 8 patients (7%) developed recurrence or conversion to squamous cell carcinoma, 6 of whom were successfully re-treated endoscopically. Two patients were irradiated, one of whom eventually underwent laryngectomy. In the T1a group 9 patients (8%) developed recurrence, two of whom were successfully re-treated endoscopically. Seven patients were irradiated. None underwent laryngectomy. Six patients developed a second or third laryngeal tumour which was treated with preservation of the larynx (CO2-laser or RT). Voice quality was better and the overall costs were lower for patients treated with CO2-laser as compared to radiotherapy. Conclusions: Assuming that the cure-rate is identical for endoscopic treatment and radiotherapy and considering that post-radiotherapy recurrence usually leads to laryngectomy (occasionally partial), 23 of these patients (11%) probably would have undergone a laryngectomy if they had been treated by radiotherapy initially. Thanks to endoscopic treatment only 1 patient (0.5%) lost his larynx. Because of ultimate laryngeal preservation, voice quality and cost-effectiveness endoscopic treatment is the treatment of choice in patients with early glottic carcinoma amendable for endoscopic treatment. 13

13 congresverslag Therapy evaluation of laryngeal carcinomas by tyrosine-pet B. van der Laan, J. de Boer, J. Pruim, F. Burlage, A. Krikke, A. Tiebosch, F. Albers, W. Vaalburg, Groningen Background: One of the major problems in head and neck oncology is determination of tumor status after radiotherapy. Positron Emission Tomography (PET) can determine tumor metabolism in vivo. The feasibility of TYR-PET with L-[1-11C]-Tyrosine (TYR) as a tracer for therapy evaluation of laryngeal squamous cell carcinomas after radiotherapy was investigated. Methods: Nineteen patients with laryngeal carcinomas underwent a TYR-PET scan (PET1) before definitive treatment. The second TYR-PET scan (PET2) was performed 3 months after radiotherapy. During the minimal follow-up period of 24 months, 6 patients had clinical suspicion of recurrent disease. In these six patients a third TYR-PET (PET3), CT imaging and biopsies were performed. Results: All pretreatment tumors were depicted by TYR-PET (PET1). Three months after radiotherapy, sensitivity and specificity of TYR-PET (PET2) for discrimination between residual tumor and post treatment tissue changes, were both 100%, and for CT, 50% and 67%, respectively. For detection of recurrent tumor during follow-up, sensitivity and specificity of TYR PET (PET3) were also 100%, and CT, 75% and 50%, respectively. TYR-PET proved favourable compared to histological confirmation of residual or recurrent tumor by biopsy. Conclusions: Dynamic TYR-PET is an accurate imaging modality for therapy evaluation in detection of residual as well as recurrent disease. R. de Bree, A. Senft, J. Brouwer, E.F.I. Comans, O.S. Hoekstra, C.R. Leemans, Amsterdam Screening for distant metastases and synchronous primary tumours below the clavicles in patients with head and neck cancer: whole body FDG-PET or chest CT? Background: The detection of distant metastases at initial evaluation may alter the selection of therapy in patients with head and neck squamous cell carcinoma (HNSCC). In a recent study we retrospectively analysed the results of conventional screening for distant metastases in HNSCC patients and found that chest CT was the single most important diagnostic technique. FDG-PET is effective in staging other tumours like lung carcinoma. The aim of this study was the comparison between chest CT and whole body FDG-PET in screning for distant metastases and synchronous primary tumours below the clavicles in patients with head and neck cancer. Methods: We prospectively studied the results of whole body FDG-PET and chest CT in 78 consecutive HNSCC patients at high risk for distant metastases. Results: Distant metastases or synchronous primary tumours were found in 13 patients: PET and chest CT detected lung metastases in 6 patients and a primary lung carcinoma in 2 patients. FDG-PET detected also a primary hepatocellular carcinoma, an intraabdominal adenocarcinoma and cervical spine metastases in one patient each, which were not detected by chest CT. Chest CT detected in 2 patients lung metastases, which were not detected by FDG-PET. FDG-PET was positive at other sites in 7 patients, which were not confirmed by conventional diagnostic techniques. CT-thorax was positive in another 7 patients, which was not confirmed during follow-up of at least 6 months. Conclusions: FDG-PET can detect distant metastases and synchronous primary tumours in HNSCC patients and may be superior to current diagnostic work-up. Cost-effectiveness is under investigation. 14

14 congresverslag Positon Emission Tomography in diagnostic imaging of head and neck cancer. A review of the literature G. Regeling, J. Pruim, A. Vissink, J.L.N. Roodenburg, Groningen Background: The last years an increasing number of studies has been published on the potential value of Positon Emission Tomography (PET) in diagnosis and treatment evaluation of head and neck cancer.the aim of this study was to critically review the literature on the value of PET for the diagnosing, treatment monitoring and therapy planning of patients with head and neck squamous cell carcinoma. Methods: Literature available in PubMed/WebSPIRS and EMBASE was selected, arranged and reviewed according to subjects of interest. Results: The majority of the studies describe a heterogeneous study population. 18F-Fluoro-deoxyglucose (FDG), a glucose analogue, is the most studied radiopharmaceutical. For detection of both unknown primary tumours and recurrences, FDG-PET has become an established method reaching a higher sensitivity and in many studies also a higher specificity than computer tomography (CT) and magnetic resonance imaging (MRI). Although limited by the resolution of PET, better results for PET compared to conventional imaging are also found for cervical lymph node detection. Other applications of PET in head and neck cancer, including the use of other tracers and combined CT-PET scanning, need further study before conclusions can be drawn regarding the clinical applicability of these modalities. Conclusions: It can be concluded that thus far FDG-PET has been proven to be of additional value in the detection of unknown primary tumours, recurrences and cervical lymph nodes. In this respect FDG-PET should be performed simultaneously with conventional diagnostic modalities. Further studies are needed evaluating the other applications of PET in head and neck cancer patients. Severe atherosclerosis of the radial artery in a free radial forearm flap precluding its use R. de Bree, J.J. Quak, J.A. Kummer, S. Simsek, C.R. Leemans, Amsterdam Background: The free radial forearm flap is the most often used free flap for head and neck reconstructions. Survival of free flaps is dependent on adequate blood supply. Methods: A 69-year old woman was scheduled for excision of a T3N0M0 oropharyngeal carcinoma, neck dissections and reconstruction with a free vascularized radial forearm flap. During the operation it appeared that the entire radial artery was almost completely obstructed by atherosclerotic plaques precluding microvascular anastomosis. Results: Despite systemic risk factors certain artery types are more prone to develop clinically manifest atherosclerosis. There are no reports on the pathology of the radial artery in free flap reconstructions. Conclusions: In head and neck cancer patients severe atherosclerosis of the radial artery is very rare, but if present makes free radial forearm flap reconstruction impossible. Therefore, only in patients with (risk factors for) peripheral vascular disease screening on radial artery stenosis must be considered. 15

15 congresverslag Seventh Symposium on Research in Head and Neck Cancer Dr. B.J.M. Braakhuis VUmc, Amsterdam E.M. Bindels 1,2, M.W.M. van den Brekel 1, A.J.M. Balm 1, A.J.M. Berns 2 Department of Otolaryngology 1 and Molecular Genetics 2, The Netherlands Cancer Institute, Amsterdam Düsseldorf, Duitsland, 4-6 september 2003 Samenvattingen van presentaties uit Nederland Development of a conditional mouse model for head and neck squamous cell carcinoma Objective: Despite advances in the management of head and neck squamous cell carcinoma (HNSCC), mortality is still rising. Development of a mouse model for HNSCC, that mimics the human situation, would be beneficial for the identification of new key genes in HNSCC tumorigenesis, and would furthermore serve as an indispensable tool for designing new treatment-modalities. Methods: Conditional mice equipped with the Cre/LoxP system are especially suited for the development of models of sporadic human carcinomas. The system can control gene (in)activation in a time and/or tissue-specific manner. Mice that express Cre either in Keratin 14 expressing tissues (K14- Cre, epithelial) or after application of ligand (tamoxifen) are crossed with mice, which harbor conditional alleles for p53, LacZ and non-conditional P16ink4a. These mice were studied for SCC tumor formation and survival. Results: We have studied the efficiency of ligand-induced gene switching in R26R reporter mice, that permits the visualization of Cre-mediated recombination via b-galoctosidase staining of tissue sections. After tamoxifen application, specific gene switching could be monitored in affected tissues, like skin and oral cavity. Subsequently, tamoxifen treatment of crosses with conditional p53 and non-conditional P16ink4a mice resulted in the induction of SCC in oral cavity and skin, although with a long latency and low incidence. The use of K14-Cre mice crossed in the same genetic background gave rise to a more efficient tumor induction in skin and oral cavity. Unfortunately, these mice have also a high tendency for mammary tumor development. Conclusions: We are able to induce SCC in skin and oral cavity with a long latency and low incidence. To increase the reliability of SCC formation in skin and oral cavity, we are currently trying to combine the two abovementioned systems, to obtain a more tightly regulated Cre-expression. Furthermore, the contribution of other conditional alleles on SCC tumorigenesis is studied. J.F. Bremmer 1, R.H. Brakenhoff 1, H.J. Ruijter-Schippers 1, C.R. Leemans 1, I. van der Waal 2, B.J.M. Braakhuis 1 Depts. of 1Otolaryngology/Head and Neck Surgery and 2 Oral and Maxillofacial Surgery/Oral Pathology, Vrije Universiteit Medical Center, Amsterdam MLPA: a novel sensitive technology to detect genetic alterations in the oral cavity and oropharynx Oral and oropharyngeal cancer (OSCC) arises in genetically altered preneoplastic mucosal lesions. These precursor lesions may be clinically (leukoplakia or erythroplakia) or histologically (dysplasia) identifiable. Histopathologic grading is currently used as a predictor of malignant 16 transformation, but is not sufficiently reliable. Our aim is to improve the early diagnosis of cancer in the oral cavity and oropharynx using a non-

16 congresverslag invasive test.it will be investigated whether a panel of genetic markers is able to identify the patients at risk. For this purpose we use MLPA, Multiplex Ligation-dependent Probe Amplification. This assay allows the measurements of numerical chromosomal alterations (gains and losses) at multiple target sequences. In practice, forty markers in a single PCR run are analyzed requiring only 20 ng of DNA (approx. 3,000 cells), enabling analysis of small samples. We have obtained reproducible data using three probe sets (120 markers all over the genome) on small samples of exfoliated cells brushed from normal mucosa. We are validating the MLPA method, by analyzing DNA from (pre)neoplastic tissues, on which loss of heterozygosity was previously assessed. These updated results will be presented. The MLPA technique has so far proved to be sufficiently sensitive, reproducible and easy to perform and thus can be considered a promising method to improve the early diagnosis of OSCC. S.J. Smeets, H.J. Ruijter-Schippers, C.R. Leemans, R.H. Brakenhoff, B.J.M. Braakhuis Dept. of Otolaryngology/Head and Neck Surgery, Vrije Universiteit Medical Center, Amsterdam Genetic characterization of multistep head and neck carcinogenesis Recent studies have made clear that three functional stages can be discriminated in the multistep process of head and neck carcinogenesis (see Braakhuis et al., Cancer Research 63, 1727, 2003). In the initial phase a stem cell acquires genetic alterations and forms a patch, a clonal unit of altered daughter cells. Additional alterations lead to the conversion into a field, an expanding preneoplastic lesion. Ultimately, clonal divergence leads to the development of one or more tumors in a field. The aim of the present study is to understand the multistep carcinogenesis, focussing on the genetic characterization of the conversion from patch to field and from field to invasive cancer. First, we showed with TP53 mutation detection and loss of heterozygosity (LOH) analysis that there is a clonal relationship between tumor and most adjacent fields, and that fields can consist of genetically related subclones. Immunostaining with Ki-67 showed that genetically altered fields have a high proliferative activity. Thus, fields are able to replace the normal epithelium by enhanced proliferation without signs of invasive growth. So far, no common LOH marker responsible for the progression from field to tumor was found using 22 microsatellite markers on six different chromosomes. Therefore Multiplex Ligationdependent Probe Amplification was implemented, a novel genomics technique using minimal amounts of template DNA. This provides information not only about losses, but also about gains with 120 markers dispersed over all chromosomes. Patches have been identified by TP53 immunostaining, and Degenerated Oligo-Primed PCR is used to enlarge the amount of template DNA to allow genetic profiling. Detection and monitoring of these precursor lesions may have profound implications for cancer prevention. Second field tumors: a new entity in head and neck oncology B.J.M. Braakhuis, C.R. Leemans, M.P. Tabor, R.H. Brakenhoff Dept. of Otolaryngology/Head and Neck Surgery, Vrije Universiteit Medical Center, Amsterdam Second primary tumors (SPT) and local recurrences (LR) are a significant problem in head and neck squamous cell carcinomas (HNSCC). Thus far, the definitions of SPT and LR are based on clinical parameters: location and time interval. Our recent molecular studies have provided new insight in HNSCC carcinogenesis leading to a better understanding of how SPT and LR develop. A crucial step is the outgrowth of a preneoplastic field of genetically altered cells that precedes HNSCC development. This field has a monoclonal origin and clonal divergence takes place during progression and eventually one subclone develops into carcinoma. The population of genetically altered cells has a high proliferative capacity (as measured by Ki-67 17

17 congresverslag positivity), indicating that fields expand and thereby replace the normal mucosal epithelium. Moreover, fields are shown to be very large (over 7 cm in diameter) and are usually not detected by routine diagnostic techniques. An important clinical consequence is that fields often remain after surgery and may give rise to (genetically related) new tumors. We have provided convincing evidence for the development of these new tumors and have designated these: second field tumors (SFT). Considering the etiological differences, we believe it is important to define in molecular terms and discriminate between an SFT, a true SPT, and a true LR. In conclusion, the development of an expanding preneoplastic field is a critical step in HNSCC development with important clinical consequences. Diagnosis and treatment of HNSCC should not be focused on the tumor only, but also on the field it developed from. R.H. Brakenhoff 1, P.J.F. Snijders 2, W.J.H. Keune 1, C.J.L.M. Meijer 2, H.J. Ruijter- Schippers 1, C.R. Leemans 1, B.J.M. Braakhuis 1 Dept. of 1 Otolaryngology/Head and Neck Surgery and 2 Pathology, Vrije Universiteit Medical Center, Amsterdam Head and neck squamous cell carcinomas with transcriptionally active HPV display a distinct genetic fingerprint Transcriptionally active high risk human papilloma viruses (HPV) are found in a subset of head and neck squamous cell carcinomas (HNSCC). We investigated whether these tumors display different genetic profiles compared to those without transcriptionally active HPV. Methods: We selected cases positive for viral DNA and positive for E6 oncogene expression (N=12) and compared these with cases positive for viral DNA and negative for E6 oncogene expression (N=8) and cases negative for both HPV DNA and oncogene expression (N=12). In the tumors, we analysed 1) TP53 mutations and 2) loss of heterozygosity (LOH) with 23 microsatellite markers at 3p, 9p, 17p, 13q, 18q and 8p to obtain a detailed genetic fingerprint. Results: The presence of E6 mrna was highly and significantly correlated with a low level of LOH, i.e. on average 15% of the tested markers at 3p, 9p, 17p and 18q, versus LOH in approximately 70% of these markers in the HPV DNA+ / E6 mrna- and HPV DNAgroups. The frequency of LOH at 13q was not different. TP53 mutations were absent in the HPV DNA+ / E6 mrna+ group, but present in the majority of the other tumors. Conclusion: The presence of transcriptionally active HPV in HNSCC was found to be associated with a distinct genetic fingerprint. H.C. Hafkamp 1, J.J. Manni1, M. Schepers 1, F.J. Bot 2, A. Haesevoets 3, S.M.H. Claessen 3, A.H.N. Hopman 3, F.C.S. Ramaekers 3, E.J.M. Speel 3. Research Institute Growth & Development (GROW), Departments of Otorhinolaryngology/ Head and Neck Surgery 1 and Pathology 2, University Hospital Maastricht, and Department of Molecular Cell Biology 3, University of Maastricht Integration of genomic HPV 16 DNA is associated with p16ink4a overexpression in tonsillar carcinomas In a previous fluorescence in situ hybridization (FISH) study, we observed human papillomavirus (HPV) type 16 DNA integration in the tumor cell genome in 21% of head and neck squamous cell carcinomas, particularly tonsillar carcinomas. Because also no p53 mutations in exons 5-8 were detected, this subset of tumors may comprise a distinct pathological entity. In order to further substantiate this hypothesis, we analyzed p16ink4a expression in 81 tonsillar carcinomas, because p16ink4a has been reported to be a specific marker for oncogenic HPVcontaining (pre)neo-plastic lesions of the uterine cervix. p16ink4a expression, clinical data as well as tobacco and alcohol consumption of patients were correlated with HPV status. Tissue sections of paraffin-embedded tonsillar carcinomas were subjected to FISH using a HPV 16-specific DNA probe to assess the frequency of tumors exhibiting HPV integration. Subsequent sections were used for immunohistochemical assessment of p16ink4a overexpression. Clinical data and alcohol and tobacco expo- 18

18 congresverslag sures of patients were obtained from medical records. FISH detected HPV 16 integration in 33 of 81 (41%) carcinomas, 32 of which also harbored diffuse p16ink4a immunostaining. In contrast, only 5 of 48 HPV-negative carcinomas did stain for p16ink4a. Thus, a very strong correlation was found between p16ink4a overexpression and HPVcontaining tonsillar carcinomas (p<0.0001). Furthermore, a significant, inverse relation was found between the presence of HPV in the tumor and tobacco and/or alcohol consumption (p ). HPV-positive carcinomas also showed to be often smaller ( 4 cm) and less well differentiated than HPV-negative tumors (p= and 0.009, respectively). Our results indicate a remarkable correlation between HPV 16 integration and p16ink4a overexpression in tonsillar carcinomas, resembling the situation for (pre)invasive lesions of the uterine cervix. This suggests that p16ink4a may be considered as an alternative biomarker for HPV detection. Together with the strongly reduced or absent exposure to tobacco and alcohol in these patients, our study provides further evidence for HPVpositive tonsillar carcinomas representing a different tumor entity. L.R. Perk 1, I. Verel 1, G.W.M. Visser 2, P. Börjesson 1, R. Boellaard 3, A.A. Lammertsma 3, C.R. Leemans 1, G.A.M.S. van Dongen 1 Depts. of 1 Otolaryngology/Head and Neck Surgery, 2 Radio Nuclide Center, and 3Nuclear Medicine/PET center, Vrije Universiteit Medical Center, Amsterdam Chimeric monoclonal antibody U36 labeled with zirconium-89 for pet imaging of head and neck cancer n previously described clinical radioimmunoscintigraphy (RIS) and radioimmunotherapy (RIT) studies in our institute, the potential of the CD44v6- specific monoclonal antibody (MAb) U36 has been demonstrated. For the detection of head and neck squamous cell carcinoma (HNSCC), RIS with technetium-99m-labeled U36 IgG was found to be as valuable as the conventional imaging techniques CT and MRI, but the detection of tumor deposits smaller than 1 cm appeared to be a problem. We hypothesized that introduction of positron emission tomography (PET) might further improve tumor detection because of its high resolution. In addition, PET has potential for quantitative imaging. These features should enable PET to provide proof of principle of MAb targeting and dosimetric determinations prior to RIT. As it takes 2-4 days for intact MAbs to achieve optimal tumor-tonontumor ratios, commonly used positron emitters like carbon-11 and fluor-18 (half-lives of 20 and 100 min, respectively) are not suitable for labeling of MAbs. Therefore, we now started the exploration of the longlived positron emitter zirconium-89 (t_ = 3.27 days). For the first time, 89Zr was produced in large batches and isolated with high purity and yield. Subsequently, 89Zr was stably coupled via the chelate desferal to the chimeric MAb (cmab) U36. Biodistribution studies were performed in human HNSCC-bearing nude mice showing selective tumor targeting. On PET images, millimetersized tumors in the range of 19 to 154 mg were readily visualized. Because of these encouraging results, 89Zr-labeled MAb U36 is currently also under evaluation for its capacity to detect primary tumors and metastases in operable HNSCC patients. Initial results from this clinical PET trial will be presented at the meeting. J.A. Langendijk 1, C.R. Leemans 2, J. Buter 3, B.J. Slotman 1 1 Department of Radiotherapy, 2 Department of Otolaryngology/Head and Neck Surgery and 3 Department of Clinical Oncology of the Free University Medical Center, Amsterdam The additional value of chemotherapy to radiotherapy in locally advanced nasopharyngeal carcinoma: a meta-analysis of the published literature Purpose: The purpose of this meta-analysis was to determine the additional value of neoadjuvant (neocht), concurrent (concht) and/or adjuvant chemotherapy (adjcht) to radiation in the treatment of locally advanced nasopharyngeal carcinoma. Methods: To be eligible, full published studies had to deal with stages III and IV nasopharyngeal carcinoma and to 19

19 congresverslag have randomly assigned patients to receive conventional radiotherapy (66-70 Gy in 7 weeks) or radiotherapy combined with chemotherapy. Results: Ten randomized clinical studies were identified, including 2450 patients. The pooled HR of death for all studies was 0.82 (95%-ci: ; p=0.01) corresponding to an absolute survival benefit of 4% after 5 years. A significant interaction term (p=0.02) was found between neocht, concht and adjcht. The largest effect was found for concht with a pooled HR of 0.48 (95%-ci: ) which corresponds to a survival benefit of 20% after 5 years. With neocht, a 6% benefit was found after 5 years, which was however not statistically significant (p=0.12). The pooled RR for LRR for all studies was 0.69 (95%-ci: ). A significant effect was observed after neocht and concht, but not after adjcht. Conclusion: The addition of chemotherapy to radiotherapy in locally advanced nasopharyngeal carcinoma offers a small but significant effect on the overall survival. The largest efect was noted with the use of concht. NeoCHT led to a significant reduction of the incidence of local-regional failures, but no significant effect was observed with regard to the overall survival. No significant beneficial effect was noted with the use of adjuvant chemotherapy for any of the endpoints. Based on these results, the question arises whether the concht and adjcht (based on the results of the Intergroup study) which is currently common practice, could be improved by replacing the adjuvant part by more effective neocht combined with concht. F.J.P. Hoebers 1, D. Pluim 2, H. Bartelink 1, A.J.M. Balm 3, A.C. Begg 2, C.R.N. Rasch 1, J.H.M. Schellens 4, M. Verheij 1 1 Department of Radiotherapy, 2 Department of Experimental Therapy, 3 Department of Head & Neck Surgery, 4 Department of Medical Oncology, Antoni van Leeuwenhoek Hospital/ Netherlands Cancer Institute, Amsterdam Cisplatin-DNA adduct measurements in head and neck cancer patients treated by chemoradiotherapy Objective: Optimal dose and route of administration for chemoradiotherapy in patients with stage IV head and neck cancer of the pharynx or oral cavity is currently subject of investigation in a randomized phase III trial, comparing intra-arterial (i.a.) supradose cisplatin (150 mg/m2) (with systemic rescue by sodium-thiosulfate) and intravenous (i.v.) cisplatin (100 mg/m2). Both arms are combined with standard radiotherapy (70 Gy/7 weeks). In a subgroup of patients we studied levels of cisplatin-dna adducts in primary tumor and normal tissue. Methods: We obtained buccal cells, white blood cells (WBC) and/or tumor biopsy before and 23 hours after completion of the first course of chemoradiotherapy. Adduct levels were determined by immunocytochemistry using polyclonal antibody NKI A-59 for buccal cells. 32-P postlabeling technique was used to quantify the major adducts (GG and AG) in WBC and tumor. Chemotherapy- regime, Cisplatin-DNA adducts (in fmol/µg DNA) in: concurrently with RT: WBC Tumor GG AG GG AG 100 mg/m2 i.v. mean 0,929 0,117 3,946 0,388 SD 0,249 0,036 1,183 0, mg/m2 i.a. mean 0,826 0,093 4,070 0,373 SD 0,211 0,028 0,523 0,145 Results: So far, in 16 patients, adduct levels have been measured; 10 after i.v. and 6 after i.a. cisplatin infusion. Tumor sites were oropharynx (n=10), oral cavity (n=3) and hypopharynx (n=3). Normal tissue samples were obtained from all 16 patients, primary tumor from 10 patients with tumors, accessible for biopsy. See table for results of adduct-levels in tumor and WBC. The difference between adduct levels in WBC and primary tumor was statistically significant (p<0.02) for both i.a. and i.v. treated patients. There were no differences in adduct levels in either WBC or tumor between the i.a. and i.v. group. Analysis of adducts in buccal cells is ongoing. Conclusions: Cisplatin-DNA adduct levels in primary tumor of H&N cancer are 4- fold increased compared to WBC, both after supradose i.a. and conventional i.v. cisplatin-based chemoradiation. Despite the selective supradose i.a. administration of cisplatin, adduct levels in primary tumor are comparable to levels obtained after conventional i.v. cisplatin. Whether cisplatin-dna adduct levels correlate with treatment outcome, is subject of current research. 20

20 congresverslag S.M.G. van de Pol 1, R. de Bree 2, B.J. Slotman 1, C.R Leemans 2, J.A. Langendijk 1 1 VU medical center, Department of Radiation Oncology, 2 VU medical center, Department of Otolaryngology/Head&Neck Surgery, Amsterdam The significance of the hemoglobin level before and during surgery and postoperative radiotherapy in squamous cell carcinoma of the head and neck Objective: The objective of this retrospective study was to investigate the prognostic significance of the hemoglobin levels before and during surgery- and postoperative radiotherapy in locally advanced squamous cell carcinoma of the head and neck. Methods: 122 patients treated with curative intention were included. The hemoglobin levels were assessed before surgery (HbPS), between surgery and radiotherapy (HBAAC), before postoperative radiotherapy (HbRTpre) and at the end of radiotherapy (HbRTend). Patients were classified as anemic when the Hb-levels were < 7.5 mmol/l (females) or < 8.7 mmol/l (males), respectively. To take into account the duration of anemia during the interval between surgery and radiotherapy, the area above the curve was calculated, defined as the surface between the Hb-level and the normal Hb-value corrected for gender. Higher HbAAC values correspond with lower Hblevels. Results: In the univariate analysis, the 3-years local-regional control (LRC) among patients with an HbAAC median (high HbAAC) was 50% compared to 75% in case of an HbAAC < median (low HbAAC) (p=0.003). In addition, anemia before radiotherapy was associated with higher rates of loco-regional recurrences (p=0.03). No such association was found for the other Hb-parameters. The multivariate analysis for LRC showed that the resection margin, extranodal spread and HbAAC were independent prognostic factors. The overall survival (OS) after 3 years was 76% in case of low HbAAC and 49% in case of high HbAAC (p<0.001). In the univariate analysis, significant associations were also found for HbPS and HbRTend. The multivariate analysis for OS showed that the nodal status, HbPS and HbAAC were independent prognostic factors. Conclusions: The Hb between surgery and radiotherapy is an important prognostic factor for both LRC and OS. Pre-surgery Hb was also associated with the OS. A prospective study in which the Hb level between surgery and radiotherapy is corrected has been initiated. G.B. van den Broek, C.R.N. Rasch, F.A. Pameijer, E. Peter, M.W.M. van den Brekel, I.B.Tan, J.H. Schornagel, A.J.M. Balm NKI/AvL-AMC, Amsterdam Clinical predictors of outcome after targeted chemoradiation in advanced head and neck neoplasms Objective: To investigate which clinical and radiological parameters are predictive for local control and survival after chemoradiation in advanced head and neck cancer patients. Methods: Ninety-three inoperable patients with stage III-IV squamous cell carcinoma of the oral cavity, oropharnyx, hypopharynx and supraglottic larynx were treated with superselective-targeted chemoradiation (RADPLAT intra-arterial); all had a minimum follow-up of 2 years. Following parameters were analysed in a multivariate analysis: T-stage, N-stage, lowest involved neck level, gender, age, site, comorbidity, pretreatment hemoglobin, weight loss before treatment and uni- /bilateral infusion. The obtained significant variables in the univariate analysis and common factors like age and gender were analysed using the Cox proportional hazards model. Results: At 5 years: local control and overall survival for the whole group were 69% and 40%, respectively. Unilateral infusion (p=0.01), oropharyngeal site (p=0.02) and low N-stage (p=0.03) were predictive for local control. Gender (p=0.02), comorbidity (p=0.02), lowest involved neck level (p=0.03), age (p=0.04) and weight loss before treatment (p=0.04) were significant predictors for overall survival. Conclusion: Aside from tumour and patient characteristics unilateral infusion was an independent factor for local control. Further study incorporating tumour volume and nodal tumour volume is in its final stage. 21